Provider Demographics
NPI:1740891753
Name:BLANKE, REGINA A
Entity type:Individual
Prefix:DR
First Name:REGINA
Middle Name:A
Last Name:BLANKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA
Mailing Address - State:FL
Mailing Address - Zip Code:32169-2534
Mailing Address - Country:US
Mailing Address - Phone:850-499-3796
Mailing Address - Fax:
Practice Address - Street 1:2010 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32141-4253
Practice Address - Country:US
Practice Address - Phone:386-671-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL35824225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist